Treatments, Services and Supports

Because bipolar disorder is a chronic illness, continuous maintenance to help prevent the reemergence of symptoms is recommended. Providing proper treatment helps most individuals living with bipolar disorder control their mood swings and other symptoms.
The management of the illness should include attention to lifestyle, stress management, supports and also medication options. There is no one approach. It is essential to put together a care plan with elements specific to your needs.

If bipolar disorder is left untreated, it tends to get worse and the symptoms can become more pronounced. Recognition and diagnosis of the disorder in its earliest stages is important so that one can receive effective treatment. Effective treatment plans
usually include medication, psychotherapy, education, self-management strategies and external supports such as family, friends and formal support groups. Combining these elements and revising the treatment plan based on assessment of an individual's response
is the best means of preventing relapse and reducing the severity of symptoms.

Medications

Not everyone responds to medications in the same way. Often, multiple types of medication must be assessed in order to find the one, or ones, that are the most effective for an individual. Some of the types of medication used to treat bipolar disorder are
listed below. Information on medications can change. For the most up to date information on use and side effects contact the U.S. Food and Drug Administration (FDA) at
www.fda.gov.

Mood-stabilizing medications are often the first choice of medication when treating bipolar disorder. They are referred to as "mood stabilizers" because of their ability to return an individual to usual level of psychosocial functioning.
Except for lithium, all of the below "mood stabilizer" medications are known as anticonvulsants.

Lithium has been used for more than 50 years for the
stabilization and treatment of bipolar disorder. It is typically
more effective when administered earlier in the course of the
illness. Research has also shown that it is most effective in
those individuals with a family history of the illness and in
those experiencing the bipolar I swings between mania and
depression with a return to normal function between episodes.
The use of lithium has proved effective in helping prevent
relapse as well as beneficial in the continued treatment of
bipolar depression. There is evidence that lithium can lower the
risk of suicide but the FDA has not granted approval specifically
for this purpose.

Like all medications, lithium treatment produces side effects.
The most common unwanted effects vary in intensity with the
dose and can be effectively managed. However, for about 30
percent of people who try lithium, it is not tolerable. Lithium
side effects may include frequent urination, excessive thirst,
weight gain, memory problems, hand tremors, gastrointestinal
problems, hair loss, acne and water retention. There are two
main side effects of lithium that require monitoring by a simple
blood test: 1) hypothyroidism, which can mimic depression, and
2) impaired kidney function, which is less common, but still
needs to be monitored.

The FDA has approved valproic acid and carbamazepine for
treating mania. These drugs, also approved to treat epilepsy,
were found to be as effective as lithium for treating acute
mania and may be better than lithium in treating the more
complex bipolar subtypes of rapid cycling and dysphoric mania
as well as co-morbid substance abuse. As with lithium, valproic
acid and carbamazepine may also produce sedation and
gastrointestinal distress, but these side effects are generally
resolved within the first six months of treatment or with dose
adjustment. It is important to monitor liver function on these
medications.

Unlike valproate and carbamazepine, Lamotrigine has not
shown benefits for treatment of mania but it has approval from
the FDA for delaying occurrences of bipolar I disorder. For most
people, it produces very few side effects. Lamotrigine does not
have FDA approval for treatment of the acute episodes of
depression or mania. Studies of lamotrigine for treatment of
acute bipolar depression have produced inconsistent results.
Lamotrigine can trigger Stevens-Johnson syndrome in some
people—eight in 1,000 children and three in 1,000 adults.
Stevens-Johnson syndrome is a toxic skin condition that can
result in death. Carefully monitor your skin when taking
Lamotrigine.

All anticonvulsant medications carry an FDA warning stating
that their use may increase the risk of suicidal thoughts or
behaviors. Individuals beginning a regimen of anticonvulsant
medications for bipolar disorder or other illness should be
closely monitored for new or worsening symptoms.

Second-generation antipsychotics (SGAs) are also commonly
used to treat the symptoms of bipolar disorder and are often
paired with other medications, including mood stabilizers. They
are generally used for treating manic or mixed episodes.

These medications are often prescribed to help control acute
episodes of mania or depression. At present only quetiapine
and the combination of olanzepine and fluoxetine have FDA
approval for treatment of bipolar depression. Finding the right
preventive/maintenance medicine is not an exact science and is
specific to each individual.

Weight gain is a serious clinical concern related to the use of
all atypical antipsychotics. Not only can weight gain lead to
adult-onset diabetes and cardiovascular diseases, but being
overweight is also the leading cause of discontinuing the use of
medication.

Standard antidepressant medications are sometimes
administered to address symptoms of depression in bipolar
disorder. However, a recent study funded by the National
Institute of Mental Health (NIMH) showed that taking an
antidepressant in addition to a mood stabilizer is no more
effective that using a mood stabilizer alone for bipolar I.

These are only some of the many antidepressants that may be
prescribed for helping control the depressive symptoms of
bipolar disorder, but none has FDA approval specifically for
treatment of bipolar depression.

As with anticonvulsants, antidepressant medications also carry
an FDA warning. The FDA warning says that patients of all ages
taking antidepressants should be watched closely, especially
during the first few weeks of treatment. Possible side effects to
look for are depression that gets worse, suicidal thinking or
behavior, or any unusual changes in behavior such as trouble
sleeping, agitation or withdrawal from normal social situations.

Psychotherapy and Other Interventions

While medication is one key element in successful treatment of
bipolar disorder, psychotherapy, support groups and knowledge
about the illness are also essential components of the
treatment process. The most useful psychotherapies generally
focus on understanding the illness (psychoeducation), learning
how to cope and changing ineffective patterns of thinking. One
popular type of psychotherapy used for changing these
ineffective patterns is Cognitive Behavioral Therapy, or CBT.

Each of these components serves a critical role in helping
people recognize the specific factors that can trigger their
episodes. It is also important for individuals living with bipolar
disorder, and their families, to play active roles in learning
about the illness, and in developing and carrying out a
treatment plan of the person's choosing. This is known as
family-focused therapy.

Recently, the NIMH funded a clinical trial called the Systematic
Treatment Enhancement Program for Bipolar Disorder (STEPBD).
It showed that several psychotherapy interventions were
more advantageous in treating bipolar depression than a threesession
intervention teaching collaborative care strategies and
directing individuals to self-manage their plans. The three types
of psychotherapy examined focused on cognitive strategies,
family involvement and schedule and stress regulation.

Electroconvulsive Therapy (ECT)

For severe cases where medication and psychotherapy do not
work, ECT may be worth considering. ECT involves the use of
short electrical impulses transmitted into the brain. Although
ECT is a highly effective treatment for severe depression, manic,
or mixed episodes, it is not the first choice in providing
treatment. Although ECT still produces some side effects,
including some memory loss, modern techniques carried out
under general anesthesia are much safer than previously used
methods. As with other interventions, the risks and benefits of
ECT should be carefully reviewed.

Complementary and Alternative Medicine

CAM refers to alternative forms of medicine that are not
considered part of conventional (Western) medicine. In recent
years, CAM has become increasingly popular, but no CAM
strategy has won FDA approval. While there is still limited data
showing support for many CAM practices and some
inconsistency in results, there are studies which support the
usefulness of CAM strategies that are considered to have
minimal if any adverse effects.

One practice that has shown
some promise for the treatment and management of bipolar
disorder, as well as other mental illnesses, are omega-3 fatty acids, which are commonly found in fish oil. Some researchers
hypothesize that omega-3 may be beneficial in treating mental
illness because of its ability to protect or support the
replenishing of neurons and connections in areas of the brain
that are affected by these illnesses.

Treatment for Women

Administering medication and treatment for women living with
bipolar disorder can sometimes be difficult. For women who
begin taking valproic acid before age 20, there may be an
increase in levels of testosterone (a male hormone). This can
lead to polycystic ovary syndrome (PCOS). PCOS is a syndrome
that causes an imbalance in a woman's female sex hormones.
This can result in changes in a woman's menstrual cycle, skin
changes, small cysts in the ovaries and other problems. Most of
these symptoms will improve after stopping treatment with
valproic acid.

Pregnant women and nursing mothers living with bipolar
disorder should talk to their doctors about the benefits and
risks of all available treatments. The mood stabilizing
medications used today can hurt a developing fetus or nursing
infant. However, stopping medications, suddenly or gradually,
greatly increases the risk that bipolar symptoms will recur
during pregnancy, which compounds risk for mother and baby
alike.

Treatment for Children

The childhood diagnosis of bipolar disorder has received a great
deal of attention and has also generated controversy. Getting a
comprehensive evaluation of a child's health and mental health is important before making any psychiatric diagnosis.

In young children, bipolar is most commonly diagnosed at the
age of 12. Children who live with bipolar disorder may also have other co-occurring conditions. These can include
attention-deficit hyperactivity disorder, posttraumatic stress
disorder, learning disabilities and even substance abuse
problems. Each of these co-occurring conditions requires a
thoughtful and individualized treatment plan. Appropriate
treatment for children should include psychotherapy and
psychosocial interventions as the first line of treatment before
medications are introduced.

Treatment and Culture

African Americans and Latinos are more prone to misdiagnosis,
likely due to differing cultural or religious beliefs or language
barriers. For anyone who has received a diagnosis of bipolar
disorder, it is important to look for a health care professional
who understands a person's cultural background and shares the
same expectations for treatment.

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